Early Diagnosis Of Gastric Carcinoma

1. Early Diagnosis Of Gastric Carcinoma
Dr Lalit K Shah
Resident 1st year
General Surgery

2. Anatomy

3. Arterial Supply

4. Nerve Innervation

5. Lymphatic Drainage

6. Introduction
• The first description of stomach cancer documented in
Western literature is generally thought to be that of
Avicenna (980-1037)
• Many years later in1761, Morgani published a manuscript
on malignancies of the stomach

7. • In 1879, Pean was believed to perform the first gastric resection
for cancer
• Followed by Billroth performing the first described pyloric
resection in 1881, and
• Schlatter successfully performing the first total gastrectomy (TG)
in 1897
• In 1951, McNeer et al recommended a more extensive resection
for cancer, including TG with distal pancreatectomy and
splenectomy

8. Epidemiology
• Gastric cancer (GC) is the third leading cause of cancer-
related death worldwide, significant differences in its
incidence exist across the continents
• Higher incidence is found in Japan and Eastern Asia
(approximately 18-25 cases/100,000) than in Europe and
North America (approximately 8-10 cases/100,000)
I.G. Estimated cancer incidence, mortality, and prevalence worldwide in 2012.
http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx. 2012. Accessed October 30, 2015.

9. • Gastric cancer is a malignant solid organ tumor of older
adults (>65 years)
• The median age of diagnosis is 69 years of age
• In recent years, the incidence of GC has been rising in
younger adults (age <50 years)
• Younger patients were more likely to present with
advanced or metastatic disease

10. • In addition to age, race and ethnicity also impact the
presentation, treatment, and prognosis of GC
• In the United States, Caucasians typically present with
proximal GC, often involving the gastroesophageal
junction (GEJ)
• Asians tend to present with early stage disease, distal
tumors, and have a more favorable prognosis
Al-Refaie WB, Tseng JF, Gay G, et al. The impact of ethnicity on the presentation and prognosis of
patients with gastric adenocarcinoma. Results from the National Cancer Data Base. Cancer.
2008;113(3):461–469

12. Classification

13. Lauren Classification Vienna Classification

15. Diagnosis
• Detailed History
• Thorough Physical Examination
• Appropriate Investigations

16. History
• The symptoms of gastric cancer are generally vague and
nonspecific, contributing to its frequently advanced stage
at the time of diagnosis

17. • The most common presenting symptoms for gastric
cancers are
-non-specific weight loss, -hematemesis,
-persistent abdominal pain, -dysphagia*,
-anorexia, -nausea,
-early satiety, and -dyspepsia
(*Dysphagia more common in proximal gastric cancer)

18. • Patients presenting with a locally-advanced or metastatic
disease usually present with
-significant abdominal pain, -potential ascites,
-weight loss, -fatigue and
-can have a gastric-outlet obstruction.

21. Most patients with early gastric cancer present with symptoms
indistinguishable from benign peptic ulcer disease. Screening for this
group of patients improves detection rate of early gastric cancer and
therefore its prognosis. Endoscopy for surveillance of premalignant
lesions has been explored with this objective in mind.

22. Examination
-Presence of anemia/jaundice
-supraclavicular (Virchow node)
-axillary (Irish node)
-periumbilical (Sister Mary
Joseph node) adenopathy

23. • Evidence of intra abdominal metastases such as
hepatomegaly, jaundice, or ascites.
• Drop metastases to the
-ovaries (Krukenberg tumor) may be detectable on pelvic
examination, and
-peritoneal metastases can be felt as a firm shelf (Blumer
shelf) on rectal examination

24. • Other signs
-sign of leser trelat
-acanthosis nigricans
-Trouseau’s syndrome

25. Investigations

26. 1. Upper GI Endoscopy
• Patients presenting with any symptoms suspicious for
gastric cancer should undergo an upper endoscopy over
barium study (except for linitis plastic presenting as
leather-flask appearance)
• Although upper endoscopy is more invasive and costly, it
offers tissue diagnosis by direct biopsy
• Sensitivity and specificity is >90%

27. • Any suspicious gastric ulcer should be biopsied multiple
times for higher diagnostic accuracy (one (70%) versus
seven (98%) sensitivity)

29. • Brush cytology increases the sensitivity of single biopsies,
but the extent to which it enhances diagnostic yield when
7 biopsies are obtained remains unknown
• If bleeding with biopsy is of concern, it is reasonable to
brush the ulcer base since the risk of bleeding from this
technique is negligible
Wang, Acta cytol et al. 2002;35:195

31. 2. Barium studies
• can identify both malignant GUs and infiltrating lesions
• some early gastric cancers also may be seen
• however false negative barium studies can occur in as
many as 50% of cases
• This is a particular problem in early GC in which the
sensitivity of barium meals may be as low as 14%

33. 3. Staging
-Biopsy
-Imaging
a. CT
-accuracy 0f 50-70% for T stage
-slightly worse accuracy for N stage compared to EUS
-20-30% with negative CT have intraperitoneal disease at
laparotomy

34. b. EUS
-most reliable nonsurgical
method to evaluate depth of
invasion
-more accurate than CT for T
stage
-The overall accuracy of EUS
is operator dependent and
ranges from 57% to 88% for T
stage and 30% to 90% for N
stage

35. c. PET
-more sensitive than CT for detection of distant metastases
-negative PET not helpful- even large tumors can be falsely
negative if metabolic activity low (signet ring cancer are not
FDG avid)
d. Laparoscopy

36. 4. Other investigation
- Routine blood investigations(CBC,LFT,RFT,etc)
- Serology
- Her2 neu testing, CEA , CA 19-9

38. Although the incidence of GC is declining, the outcomes for GC patients remain dismal because of the
lack of effective biomarkers to detect early GC and predict both recurrence and chemosensitivity. Current
tumor markers for GC, including serum carcinoembryonic antigen and carbohydrate antigen 19-9, are not
ideal due to their relatively low sensitivity and specificity. Recent improvements in molecular techniques
are better able to identify aberrant expression of GC-related molecules, including oncogenes, tumor
suppressor genes, microRNAs and long non-coding RNAs, and DNA methylation, as novel molecular
markers

41. References
• Schwartz’s Principles Of Surgery 11th edition
• Maingot’s Abdominal Operation 13th edition
• Sabiston Textbook Of Surgery 21st edition
• Bailey & Love 27th edition
• Pubmed

42. THANK YOU